Use this form to screen patients before their appointment and when they arrive for their appointment.
Have you had close contact with anyone acute respiratory illness or travelled outside of Ontario in the past 14 days?
Do you have a confirmed case of COVID-19 or had close contact with a confirmed case of COVID-19?
Do you have any of the following symptoms:
- New onset of cough
- Worsening chronic cough
- Shortness of breath
- Difficulty breathing
- Sore throat
- Difficulty swallowing
- Decrease or loss of sense of taste or smell
- Unexplained fatigue/malaise/muscle aches (myalgias)
- Nausea/vomiting, diarrhea, abdominal pain
- Pink eye (conjunctivitis)
- Runny nose/nasal congestion without other known cause
Are you 70 years of age or older, experiencing any of the following symptoms: delirium, unexplained or increased number of falls, acute functional decline, or worsening of chronic conditions?